Case report: Three contrasting presentations of acute oesophageal necrosis and the determinants of outcome.

BACKGROUND: Acute oesophageal necrosis (AEN), or "black oesophagus," is a rare but potentially lethal cause of upper gastrointestinal bleeding (UGIB), classically described in elderly men with cardiovascular comorbidity. Contemporary reports emphasize a broader clinical spectrum encompassing younger immunosuppressed and critically ill patients.

CASE DESCRIPTION: We describe three patients managed at a single tertiary Malaysian center. Case 1: a 77-year-old man with type 2 diabetes and stage 3b chronic kidney disease, not on anticoagulation, presented with coffee-ground vomitus; endoscopy revealed circumferential blackish necrosis of the distal two-thirds of the oesophagus; he was treated with submucosal adrenaline injection and supportive care and achieved complete mucosal healing at 6 weeks. Case 2: a 52-year-old woman with relapsed focal segmental glomerulosclerosis on prednisolone and ciclosporin, complicated by methicillin-sensitive Staphylococcus aureus bacteraemia, hospital-acquired pneumonia, and respiratory failure requiring intubation. On the eighth day of admission she developed haematemesis with blood-stained oropharyngeal secretions, prompting emergency bedside oesophagogastroduodenoscopy; this demonstrated severe AEN with extensive submucosal tear, intramural haematoma, and multifocal necrosis, managed conservatively with nasojejunal feeding and high-dose proton pump inhibitor, with full mucosal recovery by 76 days. Case 3: a 49-year-old woman with end-stage renal failure on continuous ambulatory peritoneal dialysis (CAPD) for 6 years, admitted with relapsing Acinetobacter baumannii peritonitis, complicated by hospital-acquired carbapenemase-producing Klebsiella pneumoniae peritonitis. Her Tenckhoff catheter was removed early and she was converted to haemodialysis; she met Sepsis-3 criteria and required intensive care. On day 49 she developed UGIB; eight sequential endoscopies demonstrated a large oesophageal clot, extensive sloughy necrotic mucosa with longitudinal ulceration, and recurrent haemorrhage requiring multimodal endoscopic hemostasis (endoclips, adrenaline, hemoblock, hemospray, tranexamic acid), with ultimate mucosal healing. Despite this, she died on day 91 from septic shock attributed to a refractory intra-abdominal infection and catheter-related candidaemia; an indirect contribution from her complicated oesophageal course cannot be excluded.

CONCLUSION: These three contrasting cases illustrate the heterogeneity of AEN and reinforce the contemporary teaching that long-term outcome is determined principally by the underlying systemic illness. AEN should be considered in any acutely unwell patient with UGIB regardless of demographic profile, including immunosuppressed and long-term dialysis recipients.